CMS 1500 Sample Claim Form & Instructions
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
To access the sample claim form, click the link below
CMS 1500 Sample Claim Form
The Security Health Plan Processing System is designed to process standard health insurance claim forms (CMS 1500) using CPT-4 Procedure Codes or Health Care Common Procedure Coding System (HCPCS) with appropriate modifiers and ICD-10-CM Diagnosis Codes.
Forward Health Topic # 17797, 1500 Health Insurance Claim Form Completion Instructions, provides details on how to complete the 1500 Health Insurance Claim Form specific for BadgerCare.See Physician’s Handbook
- Click on "Online Handbook"
- Click “I Accept” and Submit Agreement
- Under User Type, select “Provider”
- Under Program, select “BadgerCare Plus & Medicaid”
- Under Service Area, select “Physician”
- Select Claims
- Select Submission
- Select 1500 Health Insurance Claim Form Completion Instructions
Use the ForwardHealth claim form completion instructions in conjunction with the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12, prepared by NUCC, to avoid denial or inaccurate claim payment.
Information submitted in both the rendering and billing provider fields must match what is registered with the ForwardHealth. For questions or to confirm your provider enrollment please see Forward Health Topic # 474.
Rendering Provider Requirements:
ForwardHealth has the below requirements when the rendering provider is different than the billing provider in element 33a or the billing provider is registered with the State of WI as a biller only (refer to ForwardHealth Topic # 3969).
- 24i: ID Qual - Enter a qualifier of "PXC" indicating provider taxonomy, in the shaded area of the detail line. (Refer to ForwardHealth Update 2012-28: )
- 24j: Rendering provider’s NPI - Enter the 10-digit taxonomy code in the shaded area of this element and enter the rendering provider's NPI in the white area.
Billing Provider Requirements:
ForwardHealth has the below requirements for billing provider information.
- 33: Billing provider info & ph # - Enter the provider or supplier’s billing name, address, and zip+4. The address must be the physical location; not a PO Box. The ZIP code of a provider's practice location address on file with ForwardHealth must be a ZIP+4 code. The ZIP+4 code helps to identify a provider when the NPI reported to ForwardHealth corresponds to multiple enrollments and the reported taxonomy code does not uniquely identify the provider. See Forward Health Topic #5097
- 33b: Billing provider taxonomy – Enter the qualifier “PXC" plus 10-digit billing provider taxonomy.
Electronic claim submission:
Electronic Payer ID: 39045
For specific information regarding electronic claims submission, please see Electronic Claims Submission.
Paper claim submission:
Paper claims can be mailed to:
Security Health Plan
P.O. Box 8000
Marshfield, WI 54449-8000
Security Health Plan uses optical character recognition (OCR) software when processing paper claims. OCR software processes claim forms by reading text within fields on the claim form utilizing scanners to create an image. This software speeds paper claim processing if claim forms are completed correctly. Tips for submitting error-free paper claim submission:
- Use only a CMS 1500 (02-12) red and white claim form – claim forms that are black and white may darken upon scanning resulting in certain fields to be un-readable, resulting in claim denials
- Use black ink only
- Required information must be filled in completely, accurately, and legibly.
- Accurately align text within the individual fields on the claim form
- Do not highlight data on the claim form; this shows as black on the scanned image
- Do not staple, clip, or tape anything to the claim form
- All attachments should be one sided; do not print double sided
- If submitting an attachment intended for claim forms, please put a copy of the attachment behind each claim form
- Place all necessary documentation in the envelope behind the claim form on a 8 x 11 sheet of paper; do not submit additional notes on post-its or paper size smaller than 8x11